Coercion and Compulsion in community mental healthcare

Andrew Molodynski

Department of Social Psychiatry, Oxford

Context

• Continuing change in the locus of psychiatric care through deinstitutionalisation

• Began in the mid part of the last century and has continued apace

• Happening in most western countries, with varying speed and varying levels of community provision

Recent UK developments

• NSF modernisation teams( assertive outreach, early intervention, and crisis teams):

• Allow more intensive long and short term support in the community

• More palatable• ‘in vivo’ treatment with minimal disruption• Expensive• Potentially allow for more coercive treatment as

better resourced and more intensive

Mental health act amendments

• Have recognised this changing locus of care and coercion/compulsion

• Have helped to focus minds upon the debate regarding these crucial issues and professional accountability within services

Main changes

• Approved Mental health Practitioners (AMHPs)

• Responsible Clinicians (RCs)

• Detention criteria change ‘slightly’

• Community Treatment Orders (CTOs)

CTOs

• Only for those already detained in hospital ( or on S25 at 1st)

• To be considered once patient having any significant leave ( 1 week)

• Renewable• Rights of appeal• Potentially wide ranging conditions:

residencefreedom of movementattendence for therapy sessionsmedication

Evidence

• Cohort studies and naturalistic data suggest an effect in terms of service use and clinical outcome

• Randomised trials and before and after analyses have shown no statistically significant results

• “ More research urgently needed” as current evidence suggests a number needed to treat of 85 to prevent 1 admission (Cochrane review 2007)!!

But……

• Swartz et al 1999• Large US RCT of 250 patients• Found no overall significant effects• A subgroup of people kept on orders for up to a

year and receiving weekly (at least) support had reduced readmission rates (57%fewer readmissions and 20 days less overall and 72% and 28 days if psychotic)

• Concluded that they may work, but only with high levels of support ( for US)

Questions

• Are they really much different to S17 leave?

• Are they any more useful than S25?

• Do they reduce symptoms and improve functioning?

• Are they palatable, and to whom?

• Will we use them?

The Oxford Community Treatment Order Evaluation Trial (OCTET)

• Randomised controlled trial

• 300 patients, half assigned to CTO and half assigned to current management (S17 etc)

• 1 year follow up

• Clinical outcomes, satisfaction, hospital use, adverse events , economics, carer perspectives

Wider Context

• It’s not that we don’t use coercion

• However, we struggle to acknowledge this at times

• It is being increasingly acknowledged and attempts are being made to measure it and look for correlates etc

Treatment pressures

• Persuasion-an ‘appeal to reason’• Leverage-use of interpersonal pressure• Inducement-offers of help contingent upon

remaining well• Threat-withdrawal of support/help if

uncooperative• Compulsion-use of legislation (ie MHA)

Szmukler & Appelbaum 2000

Monahan et al 2005

• 1000 US patients( in 5 places)

• Housing leverage 23-40%

• Criminal sanction leverage 15-40%

• Financial leverage 7-19%

• Outpatient commitment 12-20%

• Childcare leverage reported but not measured systematically

Monahan…

• Leverage ubiquitous in standard mental health care

• Actual nature depended on available methods, but overall rates similar

• Correlations: substance misuse

younger

high BPRS

low GAF

long term/intensive treatment

Our Preliminary results (n=287)

0

10

20

30

40

50

60

70

AO CMHT P CMHT N SM

any leverage

Tentative conclusions…

• Leverage is very commonly reported by patients

• It is often, but not always reported negatively

• Housing(26%) and criminal justice(28%) are the most common

• Childcare leverage is important and rarely discussed

Summary

• New community powers seem to form part of a continuum of pressure rather than ‘standing alone’

• There is limited and often conflicting evidence about their effectiveness

• Where they are available they are used often

Scenarios

We will think about 3 different scenarios in which CTOs might or might not be used:

Good points

Bad points

Ethical issues

Practical issues

Any other issues

Scenario 1

• GN is a 45 yr old man with schizophrenia who lives alone. He just about manages with support but often doesn’t take medication properly and at these times often becomes unwell and can relapse and become aggressive.

• Consider a CTO to just give a depot 2 weekly

Scenario 2

• SD is a young man who lives alone. He can’t really look after his money, personal care, or shopping etc. he is psychotic much of the time despite medication and neglects himself much of the time. He is no risk to others. He is currently ready to leave the ward but is felt to need residential care of some sort, which he is reluctant to accept.

• Consider a CTO to insist on residence

Scenario 3

• PR is a 45 year old lady with a long history of relapsing psychosis. She drinks a lot, can’t really manage her affairs, and doesn’t much like medication. She is reluctant to see people and has no family support.

• She’s just about to leave hospital after a lengthy admission after a serious collapse at home after XS alcohol. Her house has been condemned by environmental health!

• Consider a CTO for residence, medication, and attendence at day centre

Scenario 1-Depot

• Doesn’t address whole person

• Minimally disruptive to routines of life

• Social care responsibility/reciprocity?

• Practicality

Scenario 2-residence

• Similar to existing powers

• Reduces self determination

• No medication

• Practicality?

• Responsibility/reciprocity?

Scenario 3-medication, residence, activity

• Cuts across many areas of life

• Does address more of the person/less narrow

• Perhaps better in terms of reciprocity?

• Practical/enforceable?

• Are these dilemmas and trade offs between self determination and treatment anything new?

• Or is it just the same old stuff dressed in different clothes??

Please do get in touch…

• Jorun.rugkasa@psych.ox.ac.uk

• andrew.molodynski@obmh.nhs.uk